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A 23 Year Old Woman who Presents with New Onset SE

A 23 Year Old Woman who Presents with New Onset SE. Brandon Wills, DO, MS Fellow, Clinical Toxicology Toxikon Consortium of Cook County Clinical Instructor in Emergency Medicine University of Illinois at Chicago. Case Presentation.

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A 23 Year Old Woman who Presents with New Onset SE

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  1. A 23 Year Old Woman who Presents with New Onset SE Brandon Wills, DO, MS Fellow, Clinical Toxicology Toxikon Consortium of Cook County Clinical Instructor in Emergency Medicine University of Illinois at Chicago

  2. Case Presentation • 23 year-old female presents to the ED with generalized seizures x 3 • Pt. found by family member initially somnolent

  3. Past Medical History & Social History • No details available (initially)

  4. Physical Exam • VS: AF; 90/50; 116; 24; 97% on NRM • Pt. having repeated brief generalized seizures with intermittent recovery • HEENT- pupils 5mm, reactive • CV- Tachy, no M/G/R • Lungs- CTAB • Skin- Warm, pink, dry

  5. Your Differential Diagnosis?

  6. Differential Diagnosis • Neurologic • Infectious etiologies • Metabolic • Endocrine • Toxicologic

  7. ED Course • What would be your initial management?

  8. ED Course • What would be your initial management? • IV, O2, Monitor • IV ativan • Bedside glucose • Send laboratory studies • CT head?

  9. ED Course • Pt. given several doses of IV ativan without improvement • Pt. was then intubated, sedated with propofol

  10. Lab Results • EKG: Sinus tach, narrow complex • HCO3- 10 • Anion gap- 25 • ABG- 6.99/28/172/7 • WBC- 25.4 • Chemistry = wnl • Utox- nl • ASA/APAP- negative • LFT’s- nl

  11. ED CourseWe Want More History • No history of seizure disorder • No history of trauma • Family members arrive with an empty bottle of INH

  12. ED Course • What would be your next step in this patient’s management?

  13. Isonicontinic Acid Hydrazide INH Structurally similar to • Pyridoxine (B6) • NAD • Nicotinic acid (Niacin)

  14. Isonicontinic Acid Hydrazide INH INH Pyridoxine (Vitamin B6) Nicotinic Acid (Niacin)

  15. Gyromitra species Rocket fuel Isonicontinic Acid Hydrazide INH Structurally Similar Toxins Monomethylhydrazine

  16. INH 426- Exposures 58- Minor 70- Moderate 80- Major 1- Deaths Gyromitra Species 44- Exposures 13- Minor 10- Moderate 0- Major 0- Deaths Hydrazine Epidemiology1 1. AAPCC 2001 TESS Data

  17. Pathophysiology

  18. INH Toxicokinetics Therapeutic dose: 5-15 mg/kg Toxic dose: >20 mg/kg significant toxicity >40 mg/kg Peak [ ]:2 hours Elimination T1/2: 70-180 minutes

  19. Clinical Manifestations Triad: 1. Refractory seizures 2. Severe metabolic acidosis 3. Coma

  20. Clinical Manifestations Early: May mimic anticholinergic toxidrome (N/V, tachycardia, ataxia, mydriasis, CNS dep.) Late: Seizures, acidosis Chronic: Hepatotoxicity

  21. Lab Studies • Chemistries • Lactate • EKG • Hepatic enzymes • +/- INH levels

  22. Treatment of Toxicity • A,B,C’s • Initial resuscitation and supportive care • Decontamination - Lavage? - Whole bowel irrigation? - Activated charcoal? • Enhanced elimination • Antidotes

  23. Treatment of Toxicity 1. A,B,C’s

  24. Treatment of Toxicity 2. Initial resuscitation and supportive care IV Fluids Benzodiazepines +/- Sodium bicarb

  25. Treatment of Toxicity 3. Decontamination - Lavage? - Whole bowel irrigation? - Activated charcoal?

  26. Treatment of Toxicity 4. Enhanced elimination Hemodialysis?

  27. Treatment of Toxicity 5. Antidotes Pyridoxine (B6)

  28. Case Course The Toxikon Consortium Toxikon is a Medical Toxicology Consortium Including Cook County Hospital, The University of Illinois Hospital, and Rush Presbyterian St. Luke's Medical Center

  29. Case Course • Recommended IV pyridoxine • Pharmacy unable to mobilize B6 • Contacted Rush antidote depot for courier • Pt. given 5g IV

  30. Case Course • Seizure activity terminated • Repeat ABG: 7.31/34/503/17 • Pt. extubated the following day • Transferred to psych facility on hospital day 3

  31. Teaching Points • Consider INH toxicity with patients presenting with refractory seizures

  32. Teaching Points • Remember to treat the patient, not the poison (A,B,C’s)

  33. Teaching Points • Gyromitra species are another source of hydrazine

  34. Teaching Points • What is the antidote for INH-induced seizures? • Pyridoxine (B6) • Dosing- gram (INH ingested):gram (B6) • Unknown ingestions, start with 5 grams IV • IV pyridoxine supplies are often limited • PO B6 may be crushed and given NG

  35. Questions???

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